Sunday, February 17, 2008

The young, adult male entered the Lawrence Memorial Hospital emergency room writhing in pain. "I think I am passing another kidney stone," he managed to croak before he doubled over.

The pain of passing a kidney stone is unimaginable and has been known to make the most stoic cry, vomit, or pass out. The patient was quickly triaged and examined. A urine sample confirmed the presence of red blood cells, which can be a sign of a passing stone. The physician who later recounted this story to me said he was eager to provide relief for this unfortunate patient - until his pleas for pain medication became more and more specific and demanding.

At this point, the seasoned emergency room staff, always on alert for the "frequent fliers" - patients who rotate from ER to ER, doctor office to urgent care center, looking for sympathetic ears to feed a drug habit - began to take a second look.

Detecting drug abusers is not always so easy, and while physicians and nurses want to relieve suffering, we have to be careful that our efforts to treat legitimate pain do not end up feeding addictions.

The Massachusetts Supreme Judicial Court has now given physicians another reason to pause before prescribing painkillers. The state's highest court allowed a lower court to hear a lawsuit resulting from a car accident in which a 75-year-old man, who was on various medications for medical ailments, killed a 10-year-old boy. The man, who had cancer, has since died, but the boy's family sued the man's physician because he had prescribed the medications without adequate (according to the lawsuit) instructions about driving.

The ruling means that providers may now face legal jeopardy for unintended consequences of prescribed medications.

I don't know whether the doctor in this case shirked his duty to his patient, but providers routinely discuss side effects of medications - whether patients follow them is an entirely different matter. It can also be hard to predict dangerous side effects. Everyone reacts differently to medication and combinations of medications. Unknown or complex drug interactions can create problems that were not predicted by research. And sometimes patients react one way when they first begin a drug regimen, and differently later on.

The SJC ruling has already had a chilling effect on my peers. Can we continue to treat patients for pain without worrying that they might get behind the wheel? Should we overreact and tell all of our patients on pain medications that they had better stick to sidewalks and mass transit? What about all the other medications besides painkillers that may have side effects that make driving unsafe?

One of my colleagues recently got in a tussle with a patient over what degree of pain relief was needed for an orthopedic injury. While physicians never want to have adversarial relationships with those in their care, the recent ruling may make these conflicts more frequent.

After giving a narcotic in the emergency room, another colleague has begun following patients to their cars if he's unsure whether they really have someone to drive them home.

Clearly, pain management is one of the most vexing problems for physicians. Recently, the Joint Commission, an accrediting board for medical institutions, put guidelines in place to ensure that providers paid enough attention to their patients' pain.

Of course, periodically an outlaw physician is arrested for running a "pill shop" where pain medications are given out indiscriminately for quick fees. But most providers want to do the right thing.

Most patients do, too, though there are some, like the man seen in the ER, who attempt to deceive physicians.

Pain is a subjective symptom and recent studies have confirmed biologic reasons for differing perceptions of pain. Providers ask patients to rate their pain using a zero-to-10 scale in an attempt to quantify their suffering. But at the end of the day, good judgment and clear patient doctor-communication is the best remedy.

While the Massachusetts case has not yet been decided, an outcome against the physician could have a chilling effect on prescribing practices. Doctors should outline possible side effects of medications, especially those that impair judgment, vision, or ability to drive safely. However, it is up to the patient to follow instructions and take responsibility.

Dr. Victoria McEvoy, medical director and chief of pediatrics of Mass. General West Medical Group and assistant professor of pediatrics at Harvard Medical School, can be reached at mcevoyvicky@gmail.com.